Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology

Abstract

key-words: ST elevation myocardial infarction -acute coronary syndromes -acute cardiac carepre-hospital -emergency medical service -networks 2 IntroductionOptimal treatment for ST-elevation myocardial infarction (STEMI) is based on a reperfusion strategy employing either primary percutaneous coronary intervention (PPCI) or thrombolytic therapy (TT). A sizable proportion of STEMI patients are not reperfused, time delays are frequently unacceptable 1 and very few patients receive all the guideline-recommended therapies in a timely manner. Decision-making in the pre-hospital setting is pivotal for optimal STEMI care, and delays in therapy cannot later be compensated.Thus, the empowerment of paramedical staff is key to successful pre-hospital STEMI management. This requires the implementation of systems of care (STEMI networks), in which the Emergency Medical Service (EMS), non-PCI-capable hospitals, and hospitals with PCI facilities cooperate closely in order to reduce the total ischaemic time, increase the number of patients receiving reperfusion therapy, and to reduce heart failure and mortality 2 . DelaysThe total ischaemic time ( Figure 1) is often unacceptably long with only 11-15% patients treated within the recommended time intervals. 3Patient delay. An early first call to the EMS is desirable as rapid diagnosis and treatment at the scene has been shown to save lives and prevent complications. The patient's decision time (PDT) has historically remained constant at between 1-3 hours. Patients with longer PDTs tend to be older, female and diabetic, with atypical symptoms. There is significant variation in the use of EMS in STEMI (28-82% patients) and in the PDTs (81-174 mins) throughout Europe. While several public initiatives have been successful in shortening PDTs, such campaigns have only a temporary impact.An integral part of the EMS is triage by the emergency medical dispatcher. First medical contact is defined as the time at which STEMI diagnosis is made using ECG, irrespective of the setting.Pre-hospital organisation. Not all patients referred for PPCI receive optimal percutaneous reperfusion (i.e.PCI performed in a timely manner by an experienced team), and even in urban locations a minority still require pre-hospital thrombolysis (PH-T) 4 . Geographical considerations and distribution of PPCI centres are two factors that contribute to the variability in European rates (5-92%). 5 The best evidence for reperfusion 3 strategies is based on in-hospital STEMI studies, and more high-quality research on the pre-hospital environment is needed. The key to diagnosis is the pre-hospital electrocardiogram (PH-ECG) 6 , interpreted on site and/or transmitted for interpretation Pre-hospital ECGThe use of the PH-ECG is widespread in some countries and has been shown to reduce the time to reperfusion and mortality in patients with STEMI. Trained paramedics can identify STEMI with a good sensitivity and specificity, with multiple studies demonstrating that PH-ECGs decrease door-to-needle (D2N) and door-to-balloon (D2B)...

Effect of ticagrelor on the serum level of hs-CRP, ESM-1 and short-term prognosis of patients with acute STEMI

“…After obtaining written informed consent, we randomly divided these patients into two groups according to the administration of ticagrelor or clopidogrel during the therapy, 54 patients in the ticagrelor group (treatment group: Load dosage of 180 mg, maintenance dosage of 90 mg/time, twice a day) and 53 patients in the clopidogrel group (control group: Load dosage of 300 mg, maintenance dosage of 75 mg/time, once a day), and performed follow-up by telephone for 30 days after the discharge of the enrolled patients. All the cases corresponded with the definition of acute myocardial infarction of the Third Global Seminar of ESC/ACCF/AHA/WHF and the Diagnostic Criteria of Acute Myocardial Infarction stipulated by the Chinese Society of Cardiology (2010) (3,4). Exclusion criteria were: i) Patients who would have severe adverse reaction to ticagrelor or were resistant to clopidogrel; ii) patients with a history of myocardial infarction or with other heart diseases and/or severe heart failure (NYHA III or IV); iii) patients who had severe hepatic or renal dysfunction; iv) patients who had history of PCI or coronary artery bypass grafting (CABG) or had accepted other types of surgeries or been injured recently; v) patients with endocrine diseases such as diabetes, and immune system diseases such as acute or chronic infections, digestive tract infections, hematological diseases, malignant tumors, rheumatic disease of connective tissues; vi) patients with severe hypertension without any drug controls, cerebrovascular diseases or peripheral vascular disease; and vii) patients who had any conditions deemed inappropriate by researchers for inclusion in the study.…”

Outcomes by Mode of Transport of ST Elevation MI Patients in the United Arab Emirates

“…Advanced prehospital management by emergency medical services (EMS) plays a crucial role in facilitating access to care and reducing mortality rates for STEMI patients 7–11. Studies have shown that transport by EMS is associated with quicker treatment, including shorter symptom-onset-to-arrival time and door-to-reperfusion time, when compared to private transport 12,13.…”

Initial complications and factors related to prehospital mortality in acute myocardial infarction with ST segment elevation

“…In our series, with a lower mean age than the above studies, complete AV block was present in 2.4% of patients. This group, along with the nearly 6% of patients with severe bradycardia, require advanced clinical management in the field during the prehospital phase 8 9 22…”